1. Senior Emergency Rooms: Building a Care System for our Senior Adult Patients Debra Steveson, BSN

2. Objectives Describe the reasons for a senior emergency room Explain the special components of care in a senior emergency room Discuss the evidence on which the senior emergency room is based Discuss current issues with drug utilization in the elderly Relate information presented to a patient case

3. Last year was the first year the Baby Boomers hit the market. Are we prepared for this new adventure in healthcare? We have two choices at this juncture in the road: we can simply hang on and hope the ride is not too bumpy or we can help drive the process….

4. “The Little Boy and the Old Man” – Shel Silverstein Said the little boy, "Sometimes I drop my spoon." Said the old man, "I do that too." The little boy whispered, "I wet my pants." I do that too," laughed the little old man. Said the little boy, "I often cry." The old man nodded, "So do I." But worst of all," said the boy, "it seems Grown-ups don't pay attention to me." And he felt the warmth of a wrinkled old hand. I know what you mean," said the little old man.”

5. U.S. Department of Health & Human Services 2011

6. Quick Facts Exempla hospitals Lutheran Medical Center’s ED population - 21% are greater than 65 years of age St. Joseph’s ED population – 37% are 65 or older Good Samaritan Medical Center’s ED population – 29% are greater than 65 years of age

7. SENIOR ED PROJECT EGSMC Primary Service Area (PSA) Statistics: About 68,900 residents are age 65+, representing 9% of the population. Seniors in the PSA are estimated to generate 37,900 ED visits annually.* 65+ population is expected to grow 5% per year during the next five years, generating an additional 10,600 ED visits per year by 2017.* In five years, seniors will represent 12% of the total PSA population. *Based on 550 ED visits per 1,000 population for residents age 65+ Source: Healthcare Cost and Utilization Project (HCUP) 2008 Nationwide Emergency Department sample (NEDS) for Community Hospitals Slide 7 Primary Service Area (PSA) where 75% of EGSMC Inpatients Reside

8. Seniors Represent Nearly 40% of the Total Population Growth between 2012 and 2017 Slide 8

9. Patients age 65+ Represent 29% of Total EGSMC Emergency Department Visits Slide 9 29%

10. The U.S. population of adults 65+ is projected to double by 2050 U.S. Population 65+ in millions

11. The challenge: Older adults use the ED more than any other age group. True or False? – Older adults use the ED more appropriately than any other age group. 11 Why a Senior ER?

12. The challenge: Older adults use the ED more than any other age group. True or False? – Older adults use the ED more appropriately than any other age group. 12 Why a Senior ER? How can these two statements both be true? Seniors visit the ED more because they are sicker than all other age groups. The solution - we need a better continuum of care to be able to take care of these patients.

13. Senior Emergency Room: A unit or a paradigm shift Physical changes of aging Psychosocial needs Co-morbidities

14. Direct support -Certified Nurses Aid -Volunteers Consultative Services -Palliative/Hospice Care -Geropsychiatry/Behavioral Health -PT/OT -Clinical Pharmacy Care Coordination -Senior ER Care Coordinator through KP and Exempla -Community Based Referral and Care Coordination Services How Is It Different? Clinical Modifications

15. The Case of Gertrude Current ED Paradigm 82 year old female via EMS from home after a trip and fall on throw rug. No head trauma. Denies LOC. Complains of right hip pain Medical history: diabetes, a-fib, coronary artery disease, depression, chronic low back pain Social history: lives alone, daughter is out-of-state Meds: coumadin, metformin, metoprolol, aspirin, simvastatin, fluoxetine, hydrocodone/acetaminophin

16. The Case of Gertrude Current ED Paradigm Roomed next to suicidal, intoxicated patient Initial vitals stable, complains of 5/10 hip pain Initial exam: anxious, trouble following directions, right forearm skin tear, right hip contusion Medicated with 4mg IV morphine X-ray of hip negative for fracture Continues to be agitated and anxious; medicated with 1mg IV ativan Physical therapy consulted for exam

17. The Case of Gertrude Current ED Paradigm Physical therapy notes patient is difficult to arouse and confused Head CT ordered, results negative for bleed Return from CT, oxygen sats low, placed on oxygen Incontinent of urine, straight cath for UA and culture Admitted secondary to altered mental status and hypoxia Treated for catheter associated UTI Discharged to SNF for rehab after 2-day inpatient stay

18. Senior Emergency Room Goal Transform care for our senior population in the ER in a manner that improves the quality, safety, and coordination of care by providing: Safe, quiet, comfortable and supportive care environment Screening for early identification of seniors at risk Education for patients and family Coordination and mobilization of appropriate post discharge resources Effective transition back into the community Provider of choice for our senior population

19. EGSMC Senior ER Screening 19 ED RN Screening 65+ Braden Morse Fall Abuse questions ISAR3 or aboveKATZ PHQ2PositiveNotify ED & PCP Mini-CogPositiveNotify ED & PCP PT/OT referral CAMPositiveNotify ED & PCP ED RN Current Process

20. Disorders of Cognition Depression - disorder of mood Dementia - multiple cognitive deficits that include memory disturbance Delirium - disturbance in consciousness and cognition that develops acutely

21. Depression Serious illness Not part of aging Affects 3-5% of people over 65 years of age Most common cause of unexplained weight loss Can be observed and measured

22. Delirium Acquired syndrome with altered level of alertness, attention and perception. Develops over short period of time Fluctuates over course of the day Sleep/awake cycle disturbance Psychomotor Mental status

23. Confusion Assessment Method Most widely accepted diagnostic instrument 1) acute onset and fluctuating course 2) inattention 3) disorganized thinking 4) altered level of consciousness Diagnosis of delirium by CAM requires presence of numbers 1 and 2 and either 3 or 4

24. Dementia Development of memory problems AND at least one additional cognitive deficit - Aphasia - Apraxia - Agnosia

25. Stages of Dementia Early Stage -Appropriate social conversation, but longer pauses -Tendency to wander off topic -Trouble recalling names of people or places or things Middle Stage - Difficulty finding words - May have difficulty following directions -Reading may still be preserved Late Stage - Unable to complete activities of daily living, totally dependent - Very limited, if any, communication - Does not recognize self or others - Facial expression no longer change – flat affect

26. Mini Cog 3 minute instrument to screen for cognitive impairment in older adults. Detects people with mild cognitive impairment, too mild to meet diagnostic criteria for dementia. – A 3 item recall test for memory – And a simply scored Clock-drawing test (CDT) Normal clock drawing- the patient places the correct time and the clock appears grossly normal

27. Mini Cog If patient answers incorrectly, do not correct the response, if the patient asks if the answer was correct, something like, “ that was pretty close” is sufficient. Do not provide any clues or hints to the correct answer Do not allow family or friends to provide hints. What were the 3 words I asked you to remember? The order of the words do not matter.

28. Mini Cog Scoring Number of correct items recalled____. If 3 then negative screen. STOP If number of correct items recalled is 1-2 Is Clock Drawing Test abnormal? -no then screen is negative - yes with an abnormal Clock Drawing then the screen is positive Notify ED physician

29. Case Review 68-yr-old female presents to ED, referred by residential assisted living facility. - was in the dining room of the facility wearing only a bed sheet, claiming that she was the Virgin Mary and that somebody had kidnapped baby Jesus. - In the ambulance on the way to the ED, patient abruptly fell asleep and when she woke up didn’t know who or where she was. - has history of mild dementia and depression. How would you go about differentiating dementia/delirium/depression? How would you communicate and care for this patient? What would you communicate to the attending physician?

30. Greatest Issues to aging Loosing Family Members, Friends, Loss Of Mobility Loss Of Drivers License Boomers Caring For Parents Parents In Nursing Homes Decrease In Reimbursement Family Changes Retirement Widowhood Declining Physical Reserves Changes In Income Shrinking Social World For Some

31. Benefits of aging Peace Comes With Age – Just being able to feel at peace with myself and the world. Staying healthy is a good way to ensure a good quality of life for the long term. Retirement Time Discounts Grandchildren Financial Stability? Lack Of Urgency (not bladder related!)

32. Normal changes of aging Vision Hearing Smell and Taste Touch Communication

33. Vision Macular Degeneration Cataracts Glaucoma Diabetic Retinopathy Hemianopsia

34. Myths of aging Old people are sick and disabled Most are in nursing homes Senility comes with old age Old people are unhappy Old people get very tranquil or very cranky No interest in sex and can’t have it anyway Few satisfactions in old age By age 70 psychological growth is complete

35. Biases Bias in Providing Preventive Care – Older adults are often excluded from disease screening tests. As a result, diseases are diagnosed when they have reached their later stages, therefore treatment becomes expensive. – Part Of Their Social History. Dr.’s Are For Sickness Lack Of Funding Bias From Lack Of Geriatric Training Gap In Primary Care Availability Medical Intervention Training For Nursing

37. Different approach to senior adults Triage interview Assessment - slower response to questions - listen to entire answer - more history, medications, and allergies - seek treatment later

38. Assessment and Interventions A – I - different approach - different challenges - safety considerations M – O Atypical presentations Therapies that could aggravate

39. Special considerations Pain Skin care Sexuality Abuse

40. Skin Care in the Senior Adult 40

41. Abuse in the Senior Adult population True or False The majority of maltreatment of seniors occur in SNF. Sexual and physical abuse are the most common. Colorado does not have mandatory reporting of senior abuse. Interview of the abused senior should never occur apart from the caregiver. 41

42. Medication considerations Beers criteria - Identifies medications and drug classes that are potentially inappropriate based on best available studies. - Lists medications that exacerbate common disease states in the elderly - Lists medications that increase delirium and altered mental status - Reports medications that have been statistically associated with falls.

43. Beware of Drug-Drug Interactions Chance of DDI nearly 100% with 8 or more drugs 1 Almost 50% of community-dwelling geriatric patients had at least one DDI 2 DDI can result in ADR or suboptimal dosing >80% of computerized DDI alerts ignored 3 1 Sloan RW. Drug Interactions. Am Fam Physician 1983; 27:229-38.

44. NSAIDS and the elderly Congestive Heart Failure: – 10-fold increased risk of CHF exacerbation requiring hospitalization in elderly Chronic Kidney Disease: – Most nephrologists recommend avoiding NSAIDs when CrCl <60 ml/min (Stage 3 CKD) GI Bleed: – ↑bleeding risk: Age>60 Concurrent anticoagulants Prior ulcer or hemorrhage Concurrent steroids ↑ bleeding risk correlates with↑duration of use!

45. Renal considerations Morphine Methadone Digoxin Bactrim Ciprofloxacin Levofloxacin Nitrofurantoin Acyclovir Famciclovir Colchicine Gabapentin Metoclopramide Glyburide Enoxaparin (Lovenox) Fondaparinux (Arixtra) Metformin Thiazide diuretics NSAIDs Spironolactione Bisphosphonates (ie. Alendronate)

46. Pain management in the elderly Increased risk of adverse effects due to increased sensitivity to opioids – Sedation, confusion, delirium, constipation, pruritus, nausea Recommendations: – “Start low, go slow” – Manage fears, expectations – Avoid long-acting opioids unless chronic pain in opioid-tolerant patient – Treat “incident” pain with short-acting agents – Use only ONE agent – Prescribe laxatives (senna, bisacodyl) – NEVER use meperidine (Demerol)

47. Drugs and Delirium in the Elderly Anticholinergics (oxybutynin) TCAs (amitriptyline) Antipsychotics Antihistamines (Tylenol PM) H2 blockers Opioids (MS Contin) Digoxin (dose > 0.25mg/d) Antihypertensives (hypotension) Alcohol Benzodiazepines (diazepam) Antiparkinsonian drugs Antibiotics Corticosteroids 47 Combining these drugs can have additive / synergistic effects!

48. Drugs and Falls in the Elderly Anticholinergics (oxybutynin, amitriptyline) – Visual changes, sedation Anticonvulsants – Ataxia, sedation Alcohol, aminoglycosides, loop diuretics, high-dose ASA – Vestibular dysfunction (balance/posture) Benzodiazepines (diazepam), antihistamines (Tylenol PM), opioids (MS Contin) – Cerebral impairment - leading to instability and sedation 48

49. Medication List for 80 year old Diazepam 5mg Q8H prn Metformin 1,000mg BID Lisinopril 10mg QD Metoprolol 50mg BID Warfarin 2mg QD Simvastatin 40mg QHS Oxybutynin 5mg Q8H Amitriptyline 75mg QHS MS Contin 15mg Q8H Tylenol PM QHS Alendronate 70mg QOW Calcium + VitD BID Digoxin 0.25mg QD 49

50. Suggestions for management Discontinue Tylenol PM, consider trazodone 25mg QHS as needed Taper diazepam – start with reducing to 5mg Q12H Decrease digoxin to 0.125 mg daily Adjust HTN medications (HR / BP low – orthostatic risk) Discontinue Metformin, consider low-dose Glipizide Change MS Contin to fentanyl 12.5 mcg Q72H and add Senna Add oxycodone IR 5 mg Q6H prn for knee pain Change amitriptyline to nortriptyline and decrease dose to 20mg QHS 50

51. How do we keep up? Point-of-care medication list including: – Herbals and Supplements – Over-the-counter Medications – “As Needed” Medications – Date/time of last dose taken – Vaccination History – Drug/food Allergies Sometimes it may be necessary to contact SNFs, Nursing homes, outpatient pharmacies, or family members if patient has altered mental status or does not know what is being taken

52. References ENA AARP www.aarp.org Administration on Aging - www.aoa.gov Independent Sector - www.independentsector.org National Council on Aging (NCOA) - www.ncoa.org Senior Corps - www.seniorcorps.org

53. Questions?